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Pediatric Shoulder Instability

Pediatric Shoulder Instability. Mark M. Scheffer, M.D. Orthopaedic Surgeon Dartmouth-Hitchcock Concord. Shoulder Anatomy. General Anatomy:. Shoulder Anatomy. Glenohumeral Ligaments:. Shoulder Anatomy. Glenohumeral Ligaments. Shoulder Anatomy. Coracoacromial Arch:. Shoulder Stability.

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Pediatric Shoulder Instability

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  1. Pediatric Shoulder Instability Mark M. Scheffer, M.D. Orthopaedic Surgeon Dartmouth-Hitchcock Concord

  2. Shoulder Anatomy • General Anatomy:

  3. Shoulder Anatomy • Glenohumeral Ligaments:

  4. Shoulder Anatomy • Glenohumeral Ligaments

  5. Shoulder Anatomy • Coracoacromial Arch:

  6. Shoulder Stability Definition: Static and Dynamic Forces that Interact to Keep the Humeral Head Centered in the Glenoid in order to Maintain Shoulder Function.

  7. Shoulder Stability • Static and Dynamic Stabilizers

  8. Shoulder Stability • Static Stabilizers: • Bone – glenoid and humeral head • Coracoacromial Arch • Labrum • Capsuloligamentous Complex

  9. Shoulder Stability • Dynamic Stabilizers • Rotator Cuff • Deltoid, Trapezius, Lat Dorsi

  10. Shoulder Instability • Classification: Traumatic vs. Atraumatic

  11. Traumatic vs. Atraumatic • TUBS vs. AMBRI • TUBS: • Traumatic • Unidirectional • Bankart Tear • Surgical Treatment C. Parker, U Tenn

  12. Traumatic vs. Atraumatic • TUBS vs. AMBRI • AMBRI • Atraumatic • Multidirectional • Bilateral • Rehab • Inferior Capsular Shift

  13. Traumatic vs. Atraumatic Unidirectional vs. Multidirectional

  14. Traumatic Dislocation • Bankart Lesion:

  15. Traumatic Dislocation • Bankart Lesion:

  16. Traumatic Dislocation • Bankart Lesion:

  17. Traumatic Dislocation • Boney Bankart Lesion:

  18. Traumatic Dislocation • Hill-Sachs Lesion:

  19. Traumatic Dislocation • Hill-Sachs Lesion:

  20. Traumatic Dislocation • Associated Injuries • Rotator Cuff Tear • Axillary Nerve Injury • Fracture – tuberosities, Salter, Glenoid

  21. Atraumatic Dislocation: • Capsule is Large, Stretched Out • Other Shoulder is also Loose • Ankle Sprains, Other Dislocations

  22. Traumatic vs. Atraumatic • Evaluation: • History • Physical Exam • Imaging • Treatment

  23. History • When did first dislocation occur? • How Many? • What Causes the Dislocation? • PT? • Other Joint Problems?

  24. History • Voluntary Component?

  25. Physical Exam • Generalized Laxity • Examine both shoulders • Range of Motion • Neuro Exam – Axillary Nerve! • Special Tests

  26. Physical Exam • Sulcus Sign:

  27. Physical Exam • Apprehension Sign:

  28. Physical Exam: • Relocation Test:

  29. Physical Exam • Impingement Test : (Kids Don’t Get Primary Impingement!)

  30. Xrays: • AP IR and ER:

  31. Xrays • Scapular Y and Axillary

  32. Xrays • West Point Axillary View:

  33. Xrays Dislocation:

  34. Xrays • Boney Bankart:

  35. Xrays: • Watch Out:

  36. MRI • Always Get an MRI/Arthrogram – Gadolineum!

  37. MRI • Multidirectional Instability:

  38. MRI • Bankart Tear:

  39. Treatment - Traumatic • Acute Reduction:

  40. Treatment - Traumatic • Sling 1 – 3 Weeks, Rehab • Very high rate of recurrence in Teens (up to 90%) • Case can be made for primary Bankart Repair

  41. Treatment - Traumatic • Surgical: • Arthroscopic Bankart • Open Bankart • Possible w/ Capsular Imbrication

  42. Treatment - Traumatic • Surgical:

  43. Treatment - Atraumatic • Rehab: • Rotator Cuff Strengthening • Scapular Stabilization Exercises TIME! – Tends to get better as people age

  44. Treatment - Atraumatic • Surgical – • Arthroscopic Capsular Imbrication • Capsular Shift (arthroscopic or open)

  45. Recurrent Dislocations • Bone Involvement: • Humerus • Increased Hill Sachs Lesion size • Glenoid • Anteroinferior Bone/Cartilage Loss

  46. Recurrent Dislocations • Bone Loss - glenoid

  47. Recurrent Dislocations • Bone Loss – Glenoid and Humeral Head:

  48. Posterior Dislocations • Seizures – can be missed (21/24 Zagreb 2003) • Electricution • Muscle Imbalance

  49. Posterior Dislocations • Reverse Hill-Sachs:

  50. Shoulder Instability Thanks!

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